I’ve always loved nurses. My mother, one of the women I admire most in the world, is one. My sister is one, too. As a doctor, I’m lucky to work with nurses every day. Unfortunately, though, in the world of electronic records and quality measurements my nurse and I work apart more than we work together.
Doctors and nurses make a great team, especially when left alone to simply care for our patients. This rarely happens today. Instead of focusing their full attention on patients, the healthcare team is routinely diverted to more mundane tasks like data entry, paper signing and insurance appeals. They’re still on the same team, only the game has changed. Instead of working cooperatively together, they often work separately. The team is not happy with their new role, but the one who really suffers is the patient.
I didn’t realize when I first became a doctor how much I would depend on nurses, but it didn’t take long to find out. My first rotation in residency was the terrifying Intensive Care Unit (ICU). I had no idea what to expect. I wore my pressed new lab coat with my name badge identifying me as “Doctor,” but was oblivious about my role, having never spent any time in an American hospital. The white coat I’d waited so long to wear didn’t magically instill in me the confidence I had hoped it would, like putting on a superhero cape.
In Polish hospitals where I began my training the doctor’s role was seemingly endless. Doctors did everything from taking blood pressures and temperatures to physically tracking down results (and wandering patients). They delivered medications. They drew blood. They were an integral part of every facet of patient care.
It was clear from my first day in residency that things were very different in American hospitals. A sympathetic nurse simplified my job for me, “You write orders in the chart and we follow them.” So, all I had to do was write down what I wanted and it would be done? The job was suddenly both simpler and less noble than that of the Polish doctor. What I’d soon realize was that these hospital employees who awaited my orders would be the very people I’d rely on most in the future to guide me, keep me sane and keep our patients safe.
Nurses were indispensable.
Every morning before ICU rounds my colleagues and I spoke with the evening nurses to find out how our patients had fared in the night under the half-asleep watch of the exhausted on-call resident. I discovered quickly that when I was the on-call ICU resident I should expect no sleep. Alarms beeped all night. The very act of clipping my pager to my lab coat caused my heart to pound. On the rare occasion that I closed my eyes for a few minutes, compassionate nurses gently shook me awake on behalf of patients needing immediate attention. A page from the ER meant an admission, a process that took at least an hour to complete. And when my work was done, the nurses took over.
I thought I’d be ahead of my childless peers, used to frequent nighttime awakenings from a hungry, crying infant. Unfortunately, this sleep deprivation was nothing like nursing a baby in the night. Not only were the awakenings unpredictable and frequent, but they also they required a different level of consciousness. A page from an observant nurse watching over my very sick patients required an instantaneous transformation to full daytime mental capacity. Lives depended on it. Sometimes I just stayed awake all night in anticipation of imminent disturbances from dying patients and sometimes because it was better to stay awake than be jarred awake forcibly.
In those early hours when the hospital halls were quiet and empty, I marveled at the dedication and knowledge of the nurses. When a patient took a turn for the worse and the resident ran out wide-eyed and terrified, the composed nurse made helpful suggestions without being asked. “Would you like me to draw up a little morphine, maybe just a milligram to start?” Or, slightly more urgently, “I’ll get the crash cart and call the senior resident, just in case.” They knew medicine, but more importantly they intimately knew their patients (and their family members).
When I was almost 5 months pregnant with my second son, I rotated through the Neonatal Intensive Care Unit (NICU). Some of the babies in the incubators were younger than the one growing inside me. I cradled my belly in my hands as I watched over these scrawny, hairless infants attached to tubes and wires. I looked carefully at their charts, taking note of the gestational age of all of the premature babies, which provided me an amazing glimpse of the development of my own unborn son.
I tried to comfort pale, wide-eyed mothers as they sang to their babies through the plastic incubators. I watched as fathers stroked them with gloved hands poked into a small opening in the side wall. Frequently, alarms blared and stricken parents were pushed aside by a team of providers rushing to save their baby. I wondered if I could ever be as strong as these brave parents. I wondered if I would ever be as knowledgeable as their doting nurses.
NICU babies’ lives were dependent on bed alarms, frightened residents, dedicated doctors and (probably most importantly) attentive nurses. There was no room for error, exhaustion or a bad day for any member of the team – a scary thought for a pregnant resident. Fortunately, the NICU nurses were an amazing source of expertise and strength. They buzzed around the unit averting disasters while calmly directing gaping residents how to help. They provided reassurance to terrified parents and consoled devastated ones.
When babies graduated from “critical condition” to “feeders and growers,” the nurses rejoiced as they deftly slipped their charges out of incubators and gently placed them into the long-waiting arms of mothers. When a baby was ready to be discharged home, it was the NICU nurse who taught the parents how to care for their unique needs and when to seek help.
Sadly, practicing medicine has changed a lot since my residency. Instead of working side by side with my nurse in the care of our patients, we often work independently on separate administrative tasks at our computers. Still, my admiration for nurses has grown since my early years as a terrified resident. I’ve worn the badge of doctor for more than two decades now yet I have no illusions about the critical importance of my nurse, even though our jobs are different. She stands in front of me like Wonder Woman, deflecting solicitors, angry patients and insurance company probes. She’s the first to offer comfort to my suffering patient and tells me when they need a little extra attention. She reminds me before I enter the exam room if my patient has recently lost a spouse or had a new grandchild.
My nurse is like a pressure-relief valve. She takes care of much of the bureaucratic busywork sifting through my piles of papers, filling out the parts she can and organizing them so I can take have a little more time with my patients. She knows which forms to complete out to allow my patients to stay on their diabetic medications when their insurance formulary changes. She stands by the fax machine, copies the paperwork, and triages the phone calls. She calls the pharmacist to confirm what medications my patients are taking when they forget their list. She calls the hospital to get discharge summaries and the specialist’s office to request test results. She collects the urine, swabs throats and nasal passages, bandages wounds, records the vitals and reviews the allergies. She cleans up the vomit, disinfects the room and brings my shivering patient an extra blanket. She’s the bad guy who gives the shots I order.
So, what does the doctor do? I wish I could report that while the nurse was working behind the scenes the doctor was in the room caring for the patient. Sometimes I am, but much of my time is devoted to activities unrelated to their direct care. I sign hundreds of papers each week, some in ink and some electronically. The volume is overwhelming. Sometimes the signature is on emergency room visits, test results performed elsewhere or reports from the specialist office. On these papers my signature just means “Yes, I saw this, please file in the chart.” I skim these papers (though I know I should read them thoroughly) because there isn’t enough time in the day for me to meticulously read them even if I wasn’t seeing patients. Other times I sign for medical equipment for a patient (like a wheelchair, CPAP machine or crutches) or for tests to be performed (like a chest x-ray, hearing evaluation or bone density).
But doctors don’t just sign their own papers, they co-sign written orders from nurse practitioners (who are able to prescribe drugs, remove skin lesions and do pretty much everything the doctor can do except apparently sign orders). This even includes orders from visiting nurses (for things that nurse practitioners actually did themselves when they worked as nurses) – things they are likely much more qualified to sign for than doctors.
The worse offenders of needless signature-seeking, though, are adult homes. Once a week when I see patients in an adult home I find a pile of notifications waiting for my signature. “Doctor aware of 3 pound weight loss over 6 months.” Or. “Doctor notified patient slid out of chair, no injuries.” And, “Doctor aware patient seen by podiatry and had nails cut.” Really? Yes, really.
I also fill hundreds of prescriptions every week. Nurses send them to me electronically with the dosage, amount to be dispensed and the refills. I click the button that sends them to the pharmacy. I don’t have time to verify that every detail on every prescription is correct. I look at the patient’s name (Do I know this patient?) and the drug (Does it require blood work and if so when was it last done?) and the dosage (Does it look like a reasonable dose?) and the amount of refills (Have they been in the office recently? If not I ask my nurse to call them for an appointment). If something doesn’t seem right, I open the chart and check myself. I can’t do this for every prescription. No doctor could. There simply isn’t enough time in the day to double check every chart for every medication that every patient takes to confirm that the information is accurate. I must trust that the prescriptions sent by my nurses are accurate and hope that the pharmacist will call if something isn’t right. Ultimately, though, I’m responsible.
Universal health care would likely eliminate much of this unnecessary paperwork, freeing up the healthcare team to do what they do best – taking care of their patients. Most doctors I know would much rather spend less time on the computer and more time talking to and caring for their patients. Doctors want to jump off the administrative hamster wheel where they work hard to get nowhere.
But they would still be running in place if it weren’t for their nurses.
A distressed friend called me recently. Her child was in a local hospital and she worried about whether it was the right place for her. “Her nurse is wonderful, though” she confided.
“A good nurse is actually the most important thing,” I told her. “But don’t tell her doctor I said that.”